Hypertensive disorder

1. HYPERTENSIVE DISORDERS IN
PREGNANCY
a

2. Introduction
.  Hypertensive disorders of
pregnancy are leading causes
of maternal mortality.

3. Definitions
Hypertension in pregnancy:
 B/P of 140/90 or more in a
previously normotensive woman.
 If there is a rise of 30 mmHg or
more in the systolic blood pressure
or 15 mmHg or more in the diastolic
blood pressure In 2 occasions 4
hours apart.

4. Classifications

5. CLASSIFICATION
 Gestational hypertension.
 Chronic hypertension with pregnancy.
 Preeclampsia (mild, severe).
 Eclampsia.
 Superimposed preeclampsia upon
chronic hypertension.

6. Definitions
 Gestational hypertension:
Hypertension for first time after 20 w,
without Proteinuria. BP returns to normal
before 12 weeks postpartum.
 Chronic hypertension with pregnancy:
Hypertension antedates pregnancy and
detected before 20 w, & lasts more than
12 weeks postpartum.

7. Definitions
Preeclampsia:
The development of hypertension after
20 w measured on two occasions at least
four hours apart with proteinuria
Eclampsia (in Greek= Flash of light):
The occurrence of tonic-clonic
convulsions (without any neurological
disease) in a woman with pre-eclampsia.

8. Definitions
Superimposed pre-eclampsia:
¤ It is the new development of
Proteinuria after 20 weeks gestation
in a patient with chronic
hypertension

9. Definitions
 Proteinuria:occurance of at least ≥
300mg of protein perlitre urine in at
least two random clean catch
midstream urine

10. Preeclampsia

11. Epidemiology of preeclampsia
Incidence:
 Is the most common medical disorder
complicating pregnancy 5-15%
 Is the most common hypertensive disorder
in pregnancy.
 More common in primigravidas and elderly
multipara.

12. Epidemiology
Risk factors:
 Chronic hypertension.
 Past history .
 Family history.
 Obesity.
 Multiple pregnancy.

13. Etiology = theories
 Genetic Predisposition.
 Free Radicals Theory
 In pre-eclampsia the levels of
free radicals are higher than
normotensive women leading to
endothelial damage.

14. Etiology= theories
Prostaglandins:
 There is decrease in prostacyclin /TX
A2 ratio leading to :
 vasoconstriction and tendency to
thrombosis.

15. Etiology= theories
Inflammatory Factors:
 Pre-eclampsia is considered an
inflammatory disease due to increased
number of activated leukocytes in the
maternal circulation.
 Immunological Factor:
 primigravida
 Multipara with 1st pregnancy from
a new husband.

16. The Constant Pathophysiological Changes
Vascular endothelial:
Damage +Dysfunction
+ Spasm

17. Multisystem Features Of Preeclampsia
Hypertension Proteinuria
Eclampsia HELLP syndrome
Intra-uterine growth restriction
Multi-organ disease
Cerebral vessels
Fetus
Liver
Systemic blood vessels Kidneys

18. Diagnosis
 I. Prediction:
High risk factors.
Rapid weight gain during the
2nd half of pregnancy (due to
occult edema).
Any increase above 3/4
kg/week in late pregnancy is
abnormal.

19. Diagnosis Of PET
Hypertension + Proteinuria
=
Two facets of a complex pathophysiological process

20. A): Signs: :
it is a disease of signs :
2 cardinal signs + or -
oedema:
Hypertension:
Proteinuria

21. + or - Edema
 The lower extremities.
 Abdominal wall, vulva or
may be generalized
anasarca.

22. Peripheral edema is not a useful
diagnostic criterion
1) it is common in normal pregnancy.
.
.

23. B) Symptoms (non
specific):
 Headache.
 Blurring of vision.
 Nausea and vomiting.
 Epigastric pain (distension of the liver
capsule)
 Oliguria or anuria

24. DIAGNOSIS OF ECLAMPSIA
Premonitor
y stage
 Clonic Stage
Tonic Stage
Coma Stage

25.  PS:Last for 10/20 seconds
-rolling of the eyes
-facial and hand muscle twitching
 T/S; Last for 30secs
-muscle spasm
-clenching of the fists and teeth
-Spasm of the diaphragm
-Bulging of the eyess

26. Clonic Stage 1-2mins
Violent contractions of the muscles
Facial congestion and foaming at the
mouth
Coma stage
Deep unconsciousness.
Further fits may occur.

27. Investigations
 A. Laboratory:
Urine: 24 hour urine, Proteinuria.
Kidney functions: serum creatinine, urea,
creatinine clearance and uric acid.
Liver functions: bilirubin, Enzyme.
Coagulation Profile: Bleeding and clotting
time

28. VI. Differential Diagnosis:
D. Convulsions With Pregnancy:
 Eclampsia.
 Epilepsy.
 Hysteria.
 Meningitis and Encephalitis.
 Tetanus.
 Tetany.
 Strychnine poisoning.
 Brain tumors.
 Uremic convulsions

29. COMPLICATION
Maternal:
 Respiratory problems
 Renal complication
 Cerebral oedema, thrombosis or haemorrhage
 Heart failure and Liver necrosis
 HELLP syndrome
 Clotting and Coagulation failure
 Physical Injuries/fractures during convulsions

30. Complication
 Birth asphyxia
 Jaundice
 Prematurity
 IUGR/Still birth (due
to placental
insufficiency)
 IUFD
FOETAL

31. Prevention
 Low dose aspirin: 75 mg/day.
Decrease TxA2 (from Platelets).
Not affect endothelial prostacyclin
(PGI2 )
 Calcium supplementation:
 Ca++ supplementation may
increase the production of
prostacyclin (PGI2 ) from
endothelial cells.

32. Treatment of preeclampsia
PRINCIPLES .
 Control of Hypertension.
 Prevention of convulsions .
 Delivery of the foetus

33. 1) Control of Hypertension:
 A)Parentral drugs:
1) Hydralazine:
It is a peripheral VD.
The best Antihypertensive drug used
during Pre-eclampsia and Eclampsia.
OTHERS
Centrally acting antihypertensives
Calcium Channal Blockers

34. Delivery of the foetus
 At term(37 weeks of gestation or more)
immediate delivery is advised through IOL.
 Other obstetric indications (e.g. IUGR) –
elective CS
 GA less than 37 weeks, conservative
treatment, in mild PE.

35. 2:Prevention of convulsion
 In severe PE, anticonvulsant drugs needed
to prevent the progression of the condition
to eclampsia.
 Previously diazepam used.
 magnesium sulphate best drug.
 Used to treat severe/fulminating PE

36.  Resuscitation
 Controlling the fits
 Controlling the blood pressure
 Correct fluid and electrolyte imbalance
 Nursing care
 Delivery of the baby
 Post partum care to prevent further fits
and other complications
Principles of MX

37.  Position patient in left lateral position
 Abort convulsions with loading dose of magnesium
sulphate
 Clear and maintain airway
 Oxygen by face mask
 NG tube and indwelling Foley’s catheter
 IVF and take blood sample
 History and measure BP
 If DBP is equal to or more than 110mmHg, give
Hydrallazine
Resuscitation

38.  Several agents used.
 MGSO4 the best agent.
 Two main regimens available:
 Pritchard Regimen.
 Zuspans Regimen
Controlling fits

39.  Loading dose - 4g slowly IV over 5-10
minutes.
 Followed by 10gm IM (5g in each buttock).
 Subsequently, 5g IM four-hourly in alternate
buttocks
Pritchard Regimen

40. Pritchard Regimen
LOADING DOSE
Magnesium Sulphate(4g =8ml)
Diluted with 12ml of water of
injection to 20ml
(Given I.V
slowly
for5-
10mins)
Magnesium Sulphate
10g given I.M
immediately after IV
dose
Given I.M 5g
each in
alternate
buttocks
without
dilution
MAINTENANCE DOSE MgSO4 (5g)
INTRAMUSCULAR
Given 4hrly in
alternate
buttocks without
dilution until
delivery or 24
hours after last
fit.

41.  Loading dose- IV 4g slowly over 5-10 minutes,
Maintenance dose of 1g hourly given by an infusion
pump.
Zuspans Regimen

42.  Dilute the initial IV loading dose if 50% solution
is being used to 20% solution to avoid vascular
irritation.
This is done by diluting 8mls (4g) of
the 50% solution to 20mls by adding
12mls of diluent's. (using a 20ml
syringe).
 Commonly used diluents are 5% D/W,
N/S or water for injection.
Zuspans Regimen

43. Zuspans Regimen
LOADING DOSE
Magnesium Sulphate(4g
=8ml)
Diluted with 12ml of
water of injection to
20ml
(Given I.V
slowly for5-
10mins
MAINTAINANCE
DOSE
MgSO4(10g)in 500mls
or 1000mls ringers
lactate or normal
saline (rate at 1g/hr)
given
continuously
UNTIL 24 hours
EXACTLY after
delivery or after
last fit

44.  Toxic effects of MgSO4 include loss of
sensorium leading to respiratory depression
and loss of tendon reflexes.
Monitor toxicity using:
Knee jerk reflex
 Respiratory rate
 Urine output
 The first warning sign of toxicity is loss of
the knee jerk.
Detection of MgSo2

45. Should toxicity be detected:
Stop the drug
Support respiration with ambu bag and
oxygen/ventilator
Administer the antidote which is 1g of
10% Calcium gluconate given
intravenously slowly over 10 minutes

46. Controlling blood pressure
 Boluses of IV Hydrallazine.
Aim is to reduce and maintain the DBP
<110mmHg
 Where the BP cannot be controlled by
repeated boluses of Hydrallazine, it may be
put into the infusion and titrated against the
BP at the rate of 1mg per minute(100mg in
500mls of infusion over 4hourly

47. 4)Correct Fluid and electrolyte
imbalance
 Best recommended IVF is Ringers Lactate (at least
2litres in 24hrs).
 Other fluids are N/S, 5% DW or DS
 Correct electrolytes

48.  Isolation in a COOL, QUITE, well ventilated
room.
 An efficient nurse should be present.
 The following equipments must be present
Oxygen source.
Airway.
Suction apparatus.
Bed with movable head and legs with limb
ties
Nursing MX

49.  Put the patients in left lateral
positon (to avoid aspiration of
secretions) .
 Ensure patent airway and sunction
secretions where necessary.
 Insert a catheter.
 NGT may be inserted .
 Nothing by mouth and fluid chart.
Nursing MX

50. Pulse, temperature, BP and RR.
Duration of coma.
Level of consciousness
Number of convulsions
Urine output and proteinuria
Foetal heart sounds
Administration of drug
Signs of toxicity ff adm of MgSO4
Nursing MX

51.  Correct fluid and electrolyte imbalance
depending on the results of U/E
 Fluid replacement should be with caution.
 Recommended fluid is Ringer’s lactate at 1L
EVERY 12 HRLY for 24hrs
 Where not available –Normal saline and 5%
dextrose may be used
Nursing MX

52.  Regular turning of the patient every
30minutes
 Maintain strict intake and output chart
 Care of the pressure areas to avoid
decubitus ulcers
 Catheter care.
Nursing MX

53. 6)Delivery of the foetus
 Methods:
As a rule vaginal delivery is safer and
better than CS.
 However, if the delivery is not feasible
in the next 6-9 hours, caesarean section
is recommended

54. 7.POST DELIVERY CARE
 Nursing care, IVF, anticonvulsant and
antihypertensive drugs
 As the patient recovers, oral feeding can be
commenced within 24 to 48 hours.
 Oral antihypertensive drugs can be
introduced.
 Discharge after full recovery of
consciousness and stabilization of the blood
pressure.

55. Follow up
One week after discharge.
Measure vital signs.
Continue oral antihypertensive drugs
if blood pressure remains high.
Educated on the cause and prevention
in subsequent pregnancy.